MEDICARE: JOHN MALLORY NICHOLSON MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	00126924	NY
2	2084P0804X	Child & Adolescent Psychiatry Physician	00126924	NY

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
8	00490944002	OTHER		MEDICARE SENIOR BLUE

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	00490944002	OTHER	HEALTHNOW INTEGRATED
2	10020051	OTHER	CDPHP
3	53088A	OTHER	MVP
4	000490944002	OTHER	BLUE SHIELD
5	00490944002	OTHER	EMPIRE BC/BS BLUE CARD
6	11123756	OTHER	CAQH
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	00490944002	OTHER	EMPIRE BC/BS
10	04042601887	OTHER	FIDELIS
11	8U1371	OTHER	BLUE CROSS

NPI Number	:	1992730444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MALLORY NICHOLSON MD

Provider Business Mailing Address
First Line	:	3043 STATE ROUTE 4
Second Line	:
City	:	HUDSON FALLS
State	:	NY
Zip	:	12839-9632
Country	:	US
Telephone Number	:	518-747-2284
Fax Number	:	518-747-2253

Provider Business Practice Location Address
First Line	:	3043 STATE ROUTE 4
Second Line	:
City	:	HUDSON FALLS
State	:	NY
Zip	:	12839-9632
Country	:	US
Telephone Number	:	518-747-2284
Fax Number	:	518-747-2253

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	05/19/2010

2500 E 52ND ST N , CIGNA MEDICARE SERVICES
SIOUX FALLS, SD
57104-7106

Practice Phone: 605-373-0100
Practice Fax:

3043 STATE ROUTE 4
HUDSON FALLS, NY
12839-9632